4 Introduction One of CMS most important strategic goals is to improve quality of care and general health status for Medicare beneficiaries, and we continue to make enhancements to the current Star Ratings methodology to further align it with our policy goals. Predetermined 4-star thresholds were first introduced to the CY2011 Star Ratings for a subset of the performance measures as an attempt to help contracts set achievement goals. CMS predetermined 4-star thresholds are based on analysis of historical trends in plans performance in a specific measure and aimed to drive quality improvement across all plans. CMS continued to set additional predetermined 4-star thresholds over time as more measures developed adequate performance history. In the 2013 Request for Comments, we proposed moving from the current scoring methodology to a new methodology for the 2016 Star Ratings where the predetermined measure thresholds would be removed. For measures that previously had predetermined thresholds, starting in 2016 we will follow the methodology we currently use for measures without predetermined thresholds. The current specifications and methodology for all measures is available at: While CMS initial intention for establishing predetermined 4-star thresholds was to create clear expectations about performance and to give plans specific measure-level targets to achieve, we no longer feel it necessary to set artificial thresholds for quality. The Star Ratings program has continued to evolve since being introduced by CMS in Plan sponsors have more experience with CMS rating system and our expectations of high performance. Additionally, CMS provides the industry up to two years of advance notice of potential future changes through an annual Request for Comments and the Call Letter process. For the 201 Ratings, nineteen measures did not have a predetermined threshold. The 4-star thresholds were set for 22 out of 33 (67%) Part C measures and only 5 out of 13 (38%) Part D measures. Along with contributing to misclassification in star assignments, the presence of 4-star thresholds also creates perverse incentives in encouraging plans to concentrate their resources on measures with fixed known thresholds instead of focusing on a more holistic approach of higher quality for all measures. Our analysis of the 2014 Ratings showed that on average only 32% of contracts improved across the 23 Part C measures with 4-star thresholds, compared to 52% of contracts that improved across the eight Part C measures without 4-star thresholds. For Part D, on average, only 21% of contracts showed improvement across the five measures with 4-star thresholds, while 56% of contracts showed improvement across the five Part D measures without 4-star thresholds. In the graphs of the measures that have a predetermined threshold, the 4-star threshold appears as a flat horizontal line, in contrast to the other stars cut points for that measure that have changed over time. Using the 201 Ratings, our analysis showed that on average only 28% of contracts improved across the 20 Part C measures with 4-star thresholds included in the improvement measure, compared to 51% of contracts that improved across the nine Part C measures without 4-star thresholds. We found similar findings for Part D, where on average, only 24% of contracts showed improvement across the five measures with 4-star thresholds included in the improvement measure, while 63% of contracts showed improvement across the five Part D measures without 4-star thresholds. In this document, we display graphical trends of star cut points at the measure level, along with each measure s definition, data source, and whether or not there has been a preset threshold for each measure. Over the years, unless there were specification changes, we generally see gradual changes in star cut points. This relative stability in cut points from year to year should enable plans to establish a baseline for performance for each measure. Note: The Medicare Plan Finder (MPF) pricing measures is not included due to changes in measure specifications and the narrow range of thresholds. The Special Needs Plan (SNP) Care Management measure is also not included since it is a first year measure. (Last Updated 11/18/2014) Page 1

13 Measure: C10 - Care for Older Adults Medication Review Care for Older Adults Medication Review Percent of plan members whose doctor or clinical pharmacist has reviewed a list of everything they take (prescription and non-prescription drugs, vitamins, herbal remedies, other supplements) at least once a year. (This information about a yearly review of medications is collected for Medicare Special Needs Plans only. These plans are a type of Medicare Advantage Plan designed for certain types of people with Medicare. Some Special Needs Plans are for people with certain chronic diseases and conditions, some are for people who have both Medicare and Medicaid, and some are for people who live in an institution such as a nursing home.) HEDIS Cut Points: Year 1 Star Threshold 2012 < 24% 24% to < 45% 45% to < 67% 67% to < 82% Not predetermined 82% 2013 < 44% 44% to < 63% 63% to < 81% 81% to < 92% Not predetermined 92% 2014 < 51% 51% to < 65% 65% to < % % to < 92% Not predetermined 92% 2015 < 53% 53% to < 71% 71% to < % % to < 87% Not predetermined 87% (Last Updated 11/18/2014) Page 10

14 Measure: C11 - Care for Older Adults Functional Status Assessment Care for Older Adults Functional Status Assessment Percent of plan members whose doctor has done a functional status assessment to see how well they are able to do activities of daily living (such as dressing, eating, and bathing). (This information about the yearly assessment is collected for Medicare Special Needs Plans only. These plans are a type of Medicare Advantage Plan designed for certain types of people with Medicare. Some Special Needs Plans are for people with certain chronic diseases and conditions, some are for people who have both Medicare and Medicaid, and some are for people who live in an institution such as a nursing home.) HEDIS Cut Points: Year 1 Star Threshold 2012 < 22% 22% to < 43% 43% to < 62% 62% to < 78% Not predetermined 78% 2013 < 29% 29% to < 54% 54% to < % % to < 89% Not predetermined 89% 2014 < 30% 30% to < 42% 42% to < 62% 62% to < 87% Not predetermined 87% 2015 < 49% 49% to < 59% 59% to < 73% 73% to < 83% Not predetermined 83% (Last Updated 11/18/2014) Page 11

15 Measure: C12 - Care for Older Adults Pain Assessment Care for Older Adults Pain Assessment Percent of plan members who had a pain screening or pain management plan at least once during the year. (This information about pain screening or pain management is collected for Medicare Special Needs Plans only. These plans are a type of Medicare Advantage Plan designed for certain types of people with Medicare. Some Special Needs Plans are for people with certain chronic diseases and conditions, some are for people who have both Medicare and Medicaid, and some are for people who live in an institution such as a nursing home.) HEDIS Cut Points: Year 1 Star Threshold 2012 < 24% 24% to < 34% 34% to < 59% 59% to < 87% Not predetermined 87% 2013 < 27% 27% to < 41% 41% to < 56% 56% to < 78% Not predetermined 78% 2014 < 36% 36% to < 52% 52% to < 76% 76% to < 91% Not predetermined 91% 2015 < % % to < % % to < 78% 78% to < 88% Not predetermined 88% (Last Updated 11/18/2014) Page 12

25 Measure: C22 - Plan All-Cause Readmissions 40 Plan All-Cause Readmissions Percent of senior plan members discharged from a hospital stay who were readmitted to a hospital within 30 days, either for the same condition as their recent hospital stay or for a different reason. (Patients may have been readmitted back to the same hospital or to a different one. Rates of readmission take into account how sick patients were when they went into the hospital the first time. This risk-adjustment helps make the comparisons between plans fair and meaningful.) HEDIS Lower is better Cut Points: Year 1 Star Threshold 2012 > 32% > 17% to 32% > 12% to 17% > 5% to 12% Not predetermined 5% 2013 > 17% > 13% to 17% > 11% to 13% > 3% to 11% Not predetermined 3% 2014 > 21% > 14% to 21% > 11% to 14% > 9% to 11% Not predetermined 9% 2015 > 13% > 11% to 13% > 9% to 11% > 2% to 9% Not predetermined 2% (Last Updated 11/18/2014) Page 22

33 Measure: C30 - Members Choosing to Leave the Plan Members Choosing to Leave the Plan The percent of plan members who chose to leave the plan in (This does not include members who did not choose to leave the plan, such as members who moved out of the service area.) Medicare Beneficiary Database Suite of Systems Lower is better Cut Points: Year 1 Star Threshold 2012 > 19% > 15% to 19% > 11% to 15% > 7% to 11% Not predetermined 7% 2013 > 17% > 14% to 17% > 10% to 14% > 7% to 10% Not predetermined 7% 2014 > 20% > 14% to 20% > 11% to 14% > 8% to 11% Not predetermined 8% 2015 > 46% > 29% to 46% > 16% to 29% > 9% to 16% Not predetermined 9% (Last Updated 11/18/2014) Page 30

42 Measure: D04 - Members Choosing to Leave the Plan Members Choosing to Leave the Plan: MAPD The percent of plan members who chose to leave the plan in (This does not include members who did not choose to leave the plan, such as members who moved out of the service area.) Medicare Beneficiary Database Suite of Systems Lower is better Cut Points: Type Year 1 Star Threshold MAPD 2012 > 19% > 15% to 19% > 11% to 15% > 7% to 11% Not predetermined 7% MAPD 2013 > 17% > 14% to 17% > 10% to 14% > 7% to 10% Not predetermined 7% MAPD 2014 > 20% > 14% to 20% > 11% to 14% > 8% to 11% Not predetermined 8% MAPD 2015 > 46% > 29% to 46% > 16% to 29% > 9% to 16% Not predetermined 9% (Last Updated 11/18/2014) Page 39

43 Members Choosing to Leave the Plan: PDP The percent of plan members who chose to leave the plan in (This does not include members who did not choose to leave the plan, such as members who moved out of the service area.) Medicare Beneficiary Database Suite of Systems Lower is better Cut Points: Type Year 1 Star Threshold PDP 2012 > 19% > 14% to 19% > 11% to 14% > 9% to 11% Not predetermined 9% PDP 2013 > 19% > 14% to 19% > 10% to 14% > 8% to 10% Not predetermined 8% PDP 2014 > 16% > 11% to 16% > 8% to 11% > 5% to 8% Not predetermined 5% PDP 2015 > 20% > 15% to 20% > 8% to 15% > 4% to 8% Not predetermined 4% (Last Updated 11/18/2014) Page 40

52 Measure: D11 - Medication Adherence for Diabetes Medications Medication Adherence for Diabetes Medications: MAPD One of the most important ways you can manage your health is by taking your medication as directed. The plan, the doctor, and the member can work together to find ways to help the member take their medication as directed. Percent of plan members with a prescription for diabetes medication who fill their prescription often enough to cover % or more of the time they are supposed to be taking the medication. ( Diabetes medication means a biguanide drug, a sulfonylurea drug, a thiazolidinedione drug, a DPP-IV inhibitor, an incretin mimetic drug, or a meglitinide drug. Plan members who take insulin are not included.) Prescription Drug Event (PDE) data; Medicare Enrollment Database (EDB) File; Common Working File (CWF) Cut Points: Type Year 1 Star Threshold MAPD 2012 < 67.4% 67.4% to <.7%.7% to < 74.9% 74.9% to < 78.8% Not predetermined 78.8% MAPD 2013 < 68.3% 68.3% to < 72.0% 72.0% to <.7%.7% to < 79.0% Not predetermined 79.0% MAPD 2014 < 67% 67% to < 71% 71% to < 74% 74% to < 77% Not predetermined 77% MAPD 2015 < 69% 69% to < 73% 73% to < 77% 77% to < 81% Not predetermined 81% (Last Updated 11/18/2014) Page 49

53 Medication Adherence for Diabetes Medications: PDP One of the most important ways you can manage your health is by taking your medication as directed. The plan, the doctor, and the member can work together to find ways to help the member take their medication as directed. Percent of plan members with a prescription for diabetes medication who fill their prescription often enough to cover % or more of the time they are supposed to be taking the medication. ( Diabetes medication means a biguanide drug, a sulfonylurea drug, a thiazolidinedione drug, a DPP-IV inhibitor, an incretin mimetic drug, or a meglitinide drug. Plan members who take insulin are not included.) Prescription Drug Event (PDE) data; Medicare Enrollment Database (EDB) File; Common Working File (CWF) Cut Points: Type Year 1 Star Threshold PDP 2012 < 72.3% 72.3% to < 73.6% 73.6% to <.8%.8% to < 79.2% Not predetermined 79.2% PDP 2013 < 69.4% 69.4% to <.5%.5% to < 77.3% 77.3% to < 79.6% Not predetermined 79.6% PDP 2014 < 73% 73% to < 76% 76% to < 79% 79% to < 82% Not predetermined 82% PDP 2015 < 74% 74% to < 79% 79% to < 82% 82% to < 85% Not predetermined 85% (Last Updated 11/18/2014) Page

54 Measure: D12 - Medication Adherence for Hypertension (RAS antagonists) Medication Adherence for Hypertension (RAS antagonists): MAPD One of the most important ways you can manage your health is by taking your medication as directed. The plan, the doctor, and the member can work together to find ways to help the member take their medication as directed. Percent of plan members with a prescription for a blood pressure medication who fill their prescription often enough to cover % or more of the time they are supposed to be taking the medication. ( Blood pressure medication means an ACE (angiotensin converting enzyme) inhibitor, an ARB (angiotensin receptor blocker), or a direct renin inhibitor drug.) Prescription Drug Event (PDE) data; Medicare Enrollment Database (EDB) File; Common Working File (CWF) Cut Points: Type Year 1 Star Threshold MAPD 2012 < 66.3% 66.3% to <.1%.1% to < 74.8% 74.8% to < 77.9% Not predetermined 77.9% MAPD 2013 < 67.8% 67.8% to < 72.6% 72.6% to < 76.5% 76.5% to < 79.7% Not predetermined 79.7% MAPD 2014 < 68% 68% to < 72% 72% to < % % to < 79% Not predetermined 79% MAPD 2015 < 72% 72% to < 76% 76% to < 81% 81% to < 85% Not predetermined 85% (Last Updated 11/18/2014) Page 51

55 Medication Adherence for Hypertension (RAS antagonists): PDP One of the most important ways you can manage your health is by taking your medication as directed. The plan, the doctor, and the member can work together to find ways to help the member take their medication as directed. Percent of plan members with a prescription for a blood pressure medication who fill their prescription often enough to cover % or more of the time they are supposed to be taking the medication. ( Blood pressure medication means an ACE (angiotensin converting enzyme) inhibitor, an ARB (angiotensin receptor blocker), or a direct renin inhibitor drug.) Prescription Drug Event (PDE) data; Medicare Enrollment Database (EDB) File; Common Working File (CWF) Cut Points: Type Year 1 Star Threshold PDP 2012 < 71.9% 71.9% to < 73.6% 73.6% to < 76.4% 76.4% to < 79.2% Not predetermined 79.2% PDP 2013 < 71.9% 71.9% to < 76.2% 76.2% to < 78.5% 78.5% to <.7% Not predetermined.7% PDP 2014 < 73% 73% to < 76% 76% to < 79% 79% to < 81% Not predetermined 81% PDP 2015 < 72% 72% to < 76% 76% to < 81% 81% to < 84% Not predetermined 84% (Last Updated 11/18/2014) Page 52

56 Measure: D13 - Medication Adherence for Cholesterol (Statins) Medication Adherence for Cholesterol (Statins): MAPD One of the most important ways you can manage your health is by taking your medication as directed. The plan, the doctor, and the member can work together to find ways to help the member take their medication as directed. Percent of plan members with a prescription for a cholesterol medication (a statin drug) who fill their prescription often enough to cover % or more of the time they are supposed to be taking the medication. Prescription Drug Event (PDE) data; Medicare Enrollment Database (EDB) File; Common Working File (CWF) Cut Points: Type Year 1 Star Threshold MAPD 2012 < 61.6% 61.6% to < 67.4% 67.4% to <.8%.8% to <.2% Not predetermined.2% MAPD 2013 < 63.0% 63.0% to < 67.3% 67.3% to < 71.6% 71.6% to <.4% Not predetermined.4% MAPD 2014 < 63% 63% to < 68% 68% to < 71% 71% to < % Not predetermined % MAPD 2015 < 59% 59% to < 68% 68% to < 76% 76% to < 83% Not predetermined 83% (Last Updated 11/18/2014) Page 53

57 Medication Adherence for Cholesterol (Statins): PDP One of the most important ways you can manage your health is by taking your medication as directed. The plan, the doctor, and the member can work together to find ways to help the member take their medication as directed. Percent of plan members with a prescription for a cholesterol medication (a statin drug) who fill their prescription often enough to cover % or more of the time they are supposed to be taking the medication. Prescription Drug Event (PDE) data; Medicare Enrollment Database (EDB) File; Common Working File (CWF) Cut Points: Type Year 1 Star Threshold PDP 2012 < 59.9% 59.9% to < 67.8% 67.8% to < 72.3% 72.3% to <.8% Not predetermined.8% PDP 2013 < 69.2% 69.2% to < 71.4% 71.4% to < 74.3% 74.3% to < 76.6% Not predetermined 76.6% PDP 2014 < % % to < 72% 72% to < 74% 74% to < 76% Not predetermined 76% PDP 2015 < 62% 62% to < 69% 69% to < % % to < 78% Not predetermined 78% (Last Updated 11/18/2014) Page 54

Stakeholder feedback is requested on the following: 1) metrics 69 through 94; and 2) withhold measures for years 1, 2, and 3. Steward/ 1 Antidepressant medication management Percentage of members 18 years

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